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name 3 sites of constrictions of the ureters and which is the narrowest?
- pelvi-ureteric junction
- where ureter crosses pelvic brim in region of the bifurcation of the CIA
- vesico-ureteric junction: narrowest
what structure in the ureter prevents retrograde urine flow back up ureters?
flap valve in the bladder wall before they reach orifices at upper lateral angles of trigone
what size stone would you wait to spontaneously pass?
up to 4mm, wait for 2 months then intervene
name 2 contraindications to ESWL?
describe the type of pain that ureteric calculi produce? how it this different to peritonitis?
- colicky or constant loin pain radiate to groin or scrotum
- colic cannot lie still but very still in peritonitis
what do staghorn calculi contain and what causes them?
- G-ve bacilli Proteus makes urease which hydrolyses urea to ammonium making urine alkaline and precipitating struvite stone formation
- magnesium, ammonium phosphate and calcium
name 4 conditions that increase stone formation?
- hyperparathyroidism (inc calcium)
- UTI with proteus - staghorn calculi
which medications increase stone formation?
- corticosteroids increase calcium absorption
- chemotherapy induces cell breakdown and release or uric acid from purine metabolism
what are the range of modalities used to treat ureteric calculi, ranging from simple to complex?
- simple: small stone pass spontaneously, give analgesia e.g. diclofenac and antiemetic, fluids and if infection suspected give antibiotics
- ESWL: good for small stones, better for kidney rather than ureteric stones. SE haematuria, renal colic, UTI. contra in preg and coag
- ureteroscopic removal: laser, good if lower pole stone
- percutaneous nephro lithotomy: first line for STAGHORN calculi, do under US or XR guidance
- open surgery: do if anatomical abN or complex stone or other Rx failed
do ureteric calculi predispose to TCC or ureter?
no but bladder stones increase risk of bladder tumours of SQUAMOUS CELL type
what is hyperacute rejection due to? time scale?
- formation of preformed antibodies against the donor organ
- within minutes of transplantation
- Abs usually against blood group Ags
how can you minimise hyperacute rejection?
Blood group matching
what is the treatment of hyperacute rejection? and what happens if you don't?
- remove the transplanted kidney (theres no drug to reverse it)
- or SIRS will occur
what is acute rejection? timescale?
- occurs within days to weeks
- acute CELLULAR: influx of cytotoxic T cell (CD8) against HLA antigen on renal tubular cells
- acute VASCULAR: CD4 and CD8 T cell response against HLA I and II on endothelial cells and others. this is less common but harder to treat, graft kidney looks swollen and full of blood
what is chronic rejection? timescale?
- months to years
- antibody mediated VASCUALR damage, slow narrowing of vessel lumen, tubular atrophy, kidney gradually loses function
which type of treatment helps reduce acute rejection?
immunosuppression especially ciclosporin
what is graft v host disease caused by?
engraftment of donor lymphocytes into a severely immunosuppressed recipient
when does GVHD occur?
- BM transplant eg for AML aleady immunosuppressed as had chemo
- blood transfusion
how can you reduce the risk of GVHD?
- tissue matching
- T cell depletion with MAb
which 2 malignancies does ciclosporin cause?
which diseases can lead to GU fistula e.g. from bowel to bladder causing pneumaturia?
- Carcinoma of colon or bladder
- carcinoma of cervix
- obstructed labour and difficult instrumental delivery
what investigation would you use for fistula detection?
barium enema to look for extra luminal barium and the underlying cause
what type of biopsy and what type of scoring system is used for prostate cancer?
- TRUS: trans rectal ultrasound biopsy
- Gleason score
give 2 causes of urinary incontinence in women and how to manage them
- UTI: MSU, abx
- operation for prolapsed bladder - may sew stitches around bladder neck too loose or too tight: do US to see if bladder is full and enlarged
give a rare presentation of renal cell carcinoma
Name 5 complications of renal cell carcinoma
- 1. tumour spread to renal vein and may EMBOLISE to lung causing PE - during handling intraop!
- 2. bony mets - osteolytic
- 3. polycythaemia due to ectopic EPO production
- 4. left varicocele: left testicular joins left renal but right joins IVC
- 5. hypercalcaemia due to PTH production
where in the kidney does RCC arise from?
proximal convoluted tubule
how should Any boy with a first episode of a UTI be managed?
- do micturating cystourethrogram to look for VUR
if there are classic loin to groin pain and haematuria symptoms but a normal XR KUB, what would be the next investigation?
IVU - would show delayed nephrogram on that side
what is the classical history for renal cell carcinoma?
- loin pain
- mass in hypochondrium (upper quad)
if suspect bladder cancer (painless haematuria), what inv would u do?
cystoscopy and biopsy
in terms of acute testicular pain, what cause is more common in adults and what in children?
- adults: epididymo-orchitis
- children: torsion
how do you manage epididymo-orchitis?
- antibiotic cover
- scrotal US to exclude abscess - testicular necrosis
A 31-year-old man presents to the clinic with a 2-month history of a right testicular lump. This was mildly tender at first, but over the last month has become painless. what is the diagnosis?
seminoma: usually found in 30-40 yo
how to treat suspected seminoma?
radical orchidectomy as tumour doubling time is only 28 days!
how to manage testicular torsion?
- emergency surgical exploration as necrosis in 6 hrs from ischaemia!
- orchidopexy suture both down so cant tort in future
if there is unilateral scrotal pain that you CANNOT get above and the person goes to gym.. what is it?
- inguinal hernia
- need to exclude obstruction
if you can get ABOVE a scrotal swelling what is it?
how would you treat advanced prostate cancer with no mets in a 75 yo man?
hormone therapy to suppress further tumour growth
what investigation would you do in a man with incontinence 6 months post TURP?
urodynamics to identify type of incont
how would you treat a 65yo man with 6month LUTS and uroflow showing mod obstruction?
- medical treatment alpha blocker tamsulosin.
- if no response TURP
are hydroceles more common in children or adults?
do hydroceles usually communicate with the peritoneal cavity?
can hydroceles be caused by ascites?
would you find haematuria in BPH?
yes it may come from the enlarged gland
what are 2 cardinal signs of BPH?
- terminal dribbling
what are symptoms of infection or detrusor instability?
is impotence assoc. with BPH?
what changes may you see in the bladder with BOO?
- hypertrophy of muscle
which anti hypertensive drug should you not give to asthmatics?
what is the advantage of IVU over plain XR KUB?
- shows LEVEL and degree of OBSTRUCTION
- only rarely fails to identify a stone
A 40-year-old woman presents with haematuria, malaise, fever and joint pains. She recently recovered from a sore throat. Renal function is abnormal. which investigation would tell diagnosis?
renal biopsy: symptoms suggest intrinsic renal disease such as glomerulonephritis
bilateral loin mass, non tender, in a hypertensive…diagnosis?
adult polycystic kidney disease: rare hereditary cause for secondary hypertension
what should any painless swelling of the testis assumed do be?
- malignancy- so do US: if solid its most likely cancer, if cystic then benign
- over 30: seminoma
- under 30: teratoma
in which can you normally palpate the testis: hydrocele or epididymal cyst?